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Pharynx 2018 10/4/18

NAACCR 2018‐2019 Webinar Series 1

PharynxNAACCR 2018‐2019 WEBINAR SERIES

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Q&APlease submit all questions concerning the webinar content through the Q&A panel.

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We will be distributing a Q&A document in about one week. This document will fully answer questions asked during the webinar and will contain any corrections that we may discover after the webinar.

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Pharynx 2018 10/4/18


Fabulous Prizes

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Guest SpeakerWilson Apollo, Radiation Therapist and CTR

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Pharynx 2018 10/4/18


AgendaAnatomy

Occult Tumors of Head and Neck

Solid Tumor Rules

Staging◦ AJCC◦ Summary Stage◦ EOD◦ SSDI

Radiation

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Anatomy

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Anatomy

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HPV

8 Ang KK et al. N Engl J Med 2010;363:24-35

Patients with high risk HPV oropharyngeal primaries, have a much better prognosis than those that do not have high risk HPV.

Pharynx 2018 10/4/18


HPV TestingP16 Overexpression

Viral DNA by ISH test

Viral DNA by PCR test

ISH E6/E7 RNA test

RT‐PCR E6/E7 RNA test

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Occult Tumors of Head and Neck

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Pharynx 2018 10/4/18


2018 Case ScenarioPatient presents with an enlarged cervical lymph node. ◦ The lymph node is excised and is positive for squamous cell carcinoma. ◦ Metastatic deposit measured 7mm.◦ No extranodal extension

◦ The tumor is p16 negative and EBV negative.

The managing physician performs an extensive exam and is unable to find a primary tumor or any additional metastasis.

Per the physicians notes the patient had an occult tumor of the head and neck.

The patient went on to have a lymph node dissection. ◦ 24 lymph nodes removed. ◦ No metastasis identified.

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Determining Primary SiteDoes the physician think the cancer arose in a head and neck site?◦ If the physician gives multiple potential primary sites, then code primary site to C80.9.

◦ If the physician only gives head and neck sites as possible primary sites, then determine if the tumor is p16 or EBV positive.

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Pharynx 2018 10/4/18


p16 and EBV Status

EBV

Positive Negative Unknown

HPV (p16)

Positive C11.9 Nasopharynx C10.9 Oropharynx C10.9 Oropharynx

Negative C11.9 Nasopharynx C76.0 Ill‐Defined Site

of the Head and

Neck

C76.0 Ill‐Defined Site

of the Head and

Neck

Unknown C11.9 Nasopharynx C76.0 Ill‐Defined Site

of the Head and

Neck

C76.0 Ill‐Defined Site

of the Head and

Neck

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If primary site is assigned C10.9 Oropharynx

Schema Discriminator 2◦ If p16 positive ◦AJCC Chapter 10: HPV‐Mediated (p16+) Oropharyngeal Cancer

◦ EOD and Summary Stage: Oropharynx HPV‐Mediated (p16+)

◦ If p16 negative◦AJCC Chapter 11: Oropharynx (p16‐) and Hypopharynx

◦ EOD Summary Stage: Oropharynx (p16‐)

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Pharynx 2018 10/4/18


If primary site is assigned C11.9 Nasopharynx

AJCC chapter 9: Nasopharynx

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C76.0 Ill‐Defined Site of the Head and NeckSchema Discriminator 1:◦2‐5 ◦AJCC Chapter 6: Cervical Lymph Nodes and Unknown Primary Tumors of the Head and Neck

◦ EOD and Summary Stage: Cervical Lymph Nodes and Unknown Primary Tumor of the Head and Neck

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Pharynx 2018 10/4/18


2018 Case ScenarioPatient present with an enlarged cervical lymph node. ◦ The lymph node is excised and is positive for squamous cell carcinoma. ◦ Metastatic deposit measured 7mm.◦ No extranodal extension

◦ The tumor is p16 negative and EBV negative.

The managing physician performs an extensive exam and is unable to find a primary tumor or any additional metastasis.

Per the physicians notes the patient had an occult tumor of the head and neck.

The patient went on to have a lymph node dissection. ◦ 24 lymph nodes removed. ◦ No metastasis identified.

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Staging Summary ◦Primary site: C76.0◦ p16 and EBV negative

◦Occult tumor

◦Positive cervical lymph node

◦No additional metastasis

◦Lymph node dissection◦ 00/24

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Data Item Value

Tumor Size Summary

999

Regional Nodes Pos 01

Regional Nodes Ex 25

EOD Primary Tumor 800

EOD Lymph Nodes 100

EOD Mets 00

Pharynx 2018 10/4/18


Staging Summary ◦Primary site: C76.0◦ p16 and EBV negative

◦Occult tumor

◦Positive cervical lymph node

◦No additional metastasis

◦Lymph node dissection◦ 00/24

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DataItem

Value Data Items

Value

cT cT0 pT pT0

cTSuffix

pT Suffix

cN cN1 pN pN1

cN Suffix

pNSuffix

cM cM0 pM cM0

cStage 3 pStage 3Chapter 6: Page 67

Solid Tumor RulesHEAD AND NECK

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H1 Note 2When the histology is not listed in Tables 2‐10, use the ICD‐O and all updates1. 2018 ICD O 3 Coding Table

https://www.naaccr.org/implementation‐guidelines/#ICDO3

2. ICD O 3 Manual

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Pharynx 2018 10/4/18


New Histologies Coding ClarificationSquamous cell carcinoma HPV‐negative 8086

Squamous cell carcinoma HPV‐positive 8085◦Do not use a p16 test to code 8085 or 8086. ◦HPV testing must be positive by viral detection tests in order to code histology as 8085.

Per the 2018 SEER Manual◦HPV‐type 16 refers to virus type and is different from p16 overexpression (p16+).

◦HPV status is determined by tests designed to detect viral DNA or RNA. Tests based on ISH, PCR, RT‐PCR technologies detect the viral DNA or RNA; whereas, the test for p16 expression, a surrogate marker for HPV, is IHC.

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Pop QuizWhat histology would be coded to the following:◦Final diagnosis from path report is “squamous cell carcinoma”. Separate report shows tumor is p16+◦ 8070 Squamous cell carcinoma

◦Final diagnosis is “squamous cell carcinoma, HPV positive”◦ 8085 Squamous cell carcinoma, HPV positive

◦Final diagnosis is “squamous cell carcinoma”. A separate report shows HPV positive for viral DNA by ISH test◦ 8085 Squamous cell carcinoma, HPV positive

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Pharynx 2018 10/4/18


Case ScenariosSCENARIO 1 SCENARIO 2

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Multiple Primary Rule M2‐Single Tumor

Histology Rule H1‐Single histology

Primary Site C12.9

Histology 8070

Behavior 3

Clinical Grade 9

Pathological Grade 9

Post Therapy Grade

Multiple Primary Rule M2‐Single Tumor

Histology Rule H1‐Single histology

Primary Site C10.2

Histology 8070

Behavior 3

Clinical Grade C

Pathological Grade C

Post Therapy Grade

StagingAJCC

SUMMARY STAGE

EOD

SSDI

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AJCC

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AJCC Chapters‐PharynxChapter 9‐Nasopharynx

Chapter 10 HPV‐Mediated (p16+) oropharyngeal chapter

Chapter 11 Oropharynx (p16‐) and hypopharynx

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Pharynx 2018 10/4/18


Chapter 9‐NasopharynxPrimarily treated with radiotherapy +/‐ chemotherapy without resection of primary.◦Pathological classification is largely irrelevant (AJCC Manual pg. 106).

T0 used only when patient is EBV positive

Stage 4B is only assigned when patient has distant metastasis.

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Page

Chapter 10 – HPV mediated (p16+) oropharyngeal New chapter◦Patients who are high risk HPV positive (p16+) oropharyngeal have a significantly better prognosis than those that are HPV negative (p16‐).

Clinical N values and Pathological N values are different.

Clinical Stage and Pathological Stage are different.

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Page 113

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Chapter 11: Oropharynx (p16‐) and HypopharynxT0 is not a valid value for this chapter

T values are different for oropharynx and hypopharynx

N categories are different for clinical N and pathological N◦ENE + is N3b for cN

◦ENE + may be N2a or N3b for pN

If neck dissection is completed, a stage group may be assigned even if the primary tumor is not resected.

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Summary Stage & EOD

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Pharynx 2018 10/4/18


Summary Stage EOD

SUMMARY STAGE 2018

•Cervical Lymph Nodes And Unknown Primary Tumors Of Head And Neck

•Nasopharynx

•Oropharynx

•Hypopharynx

EODCervical Lymph Nodes And Unknown Primary

Hypopharynx

Oropharynx (p16‐)

Oropharynx HPV‐Mediated (p16+)

Nasopharynx

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Schema Discriminator 1C11.1 ◦Posterior wall of the nasopharynx◦ SS2018 Nasopharynx

◦Adenoid◦ SS2018 Nasopharynx

◦Pharyngeal tonsil◦ SS2018 Oropharynx

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Pharynx 2018 10/4/18


Check the manual!A tumor arising in the pyriform sinus and extending into postcricoid area.◦Localized or Regional?

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SSDI’s

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Extranodal Extension H&N Clin

Extranodal Extension H&N Path

Lymph Nodes Size of Mets

SEER_SSF1: SEER Site‐Specific Fact 1: ◦Human Papilloma Virus (HPV) Status

Pharynx 2018 10/4/18


Extranodal Extension H&N Clinical•Imaging alone is not enough to determine or exclude ENE.•Code 0 when lymph nodes are determined to be positive and physical examination does not indicate any signs of extranodal extension.•Clinical ENE is described in the AJCC 8th edition as "Unambiguous evidence of gross ENE on clinical examination• (e.g., invasion of skin, infiltration of musculature, tethering to adjacent structures, or cranial nerve, brachial plexus, sympathetic trunk, or phrenic nerve invasion with dysfunction)“

•The terms 'fixed' or 'matted' are used to describe lymph nodes.

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Extranodal Extension H&N PathologicalCode the status of ENE assessed on histopathologic examination of surgically resected involved regional lymph node(s). ◦Do not code ENE from a lymph node biopsy (FNA, core, incisional, excisional, sentinel).

◦Do not code ENE for any distant lymph node

Definitions of ENE subtypes and rules:◦Microscopic ENE [ENE (mi)] is defined as less than or equal to 2 mm.◦Major ENE [ENE (ma)] is defined as greater than 2 mm.◦ Both ENE (mi) and ENE (ma) qualify as ENE (+) for definition of pN.

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Pharynx 2018 10/4/18


Lymph Nodes Size of MetastasisRecord the size of the largest metastatic lymph node◦ If the same involved node (or same level) is examined both clinically and pathologically, record the size of the node from the pathology report, even if it is smaller.◦ Example: Clinical evaluation shows 1.5 cm (15 mm) Level II lymph node, pathological examination shows Level II 1.3 cm (13 mm) metastatic deposit. Code 13.0.

◦ If the largest involved node is not examined pathologically, use the clinical node size

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SEER_SSF1: SEER Site‐Specific Fact 1: Human Papilloma Virus (HPV) StatusRequired for SEER Registries only◦There are several methods for determination of HPV status. The most frequently used test is IHC for p16 expression which is surrogate marker for HPV infection.◦Do not record the results of IHC p16 expression in this field.◦ The rest of the tests (based on ISH, PCR, RT‐PCR technologies) detect the viral DNA or RNA.

◦ This data item is only for HPV status determined by tests designed to detect viral DNA or RNA.

◦ Leave this field blank if tests not done.

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Pharynx 2018 10/4/18


Case Scenario 1‐Staging SummaryPrimary Tumor◦ Tumor Size◦ Pre‐treatment◦ 3cm

◦ Post‐surgery◦ No surgery of primary site

◦ Extension◦ Pre‐Treatment◦ Confined to the pyriform sinus

◦ Post Surgery◦ No surgery to primary site

Lymph Nodes◦ Pre‐treatment◦ Palpable, moveable level III lymphadenopathy.

◦ Largest measured 2cm per CT◦ FNA of lymph node positive for CA

◦ Post Surgery◦ No lymph node dissection

Distant metastasis◦No indication of distant metastasis

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Tumor Size

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Data Item Value

Tumor Size Clinical

030

Tumor Size Pathological

999

Tumor Size Summary

030

Scenario 1

Pharynx 2018 10/4/18


AJCC Staging

Scenario 1 43

DataItem

Value Data Items

Value

cT cT2 pT

cTSuffix

pTSuffix

cN cN2b pN

cN Suffix

pNSuffix

cM cM0 pM

cStage 4A pStage 99

Which AJCC chapter do we use?◦Primary Site C12.9

◦Histology 8070/3

◦HPV Status Negative

Chapter 11

(f)

Summary Stage/EOD

Scenario 1 44

Data Item Value

Summary Stage 3‐R LN


EOD Regional Nodes 250

EOD Mets 00

CLINICAL or PATHOLOGICALMetastasis in MULTIPLE ipsilateral nodesNo nodes larger than 6 cm in greatest dimensionExtranodal extension (ENE) negative or unknown

Pharynx 2018 10/4/18


SSDI’s

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Data Item Value

Extranodal Extension H&N Clin 0

Extranodal Extension H&N Path X.9

Lymph Nodes Size of Metastasis 020

SEER_SSF1: SEER Site‐Specific Fact 1: Human Papilloma Virus (HPV) Status

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Case Scenario 2‐Staging SummaryPrimary Tumor◦ Tumor Size◦ Pre‐treatment◦ 2.4cm

◦ Post‐surgery◦ 2.6cm

◦ Extension◦ Pre‐Treatment◦ Laryngoscopy‐lesion arising in lateral wall of oropharynx extending to posterior tonsillar pillar.

◦ Post Surgery◦ Tumor of the right lateral wall of oropharynx extends into tonsillar pillar. No further extension

Lymph Nodes◦ Pre‐treatment◦ CT shows 2 retropharyngeal lymph nodes‐ most likely represent mets. Largest is 2.4cm. No indication of ENE.

◦ Post Surgery◦ 02/14 positive lymph nodes. ◦ Largest metastatic focus 2.1cm◦ ENE present 0.3mm

Distant metastasis◦ No indication of distant metastasis

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Pharynx 2018 10/4/18


Tumor Size

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Data Item Value

Tumor Size Clinical

024

Tumor Size Pathological

026

Tumor Size Summary

026

AJCC Staging

Scenario 2 48

DataItem

Value Data Items

Value

cT cT2 pT

cTSuffix

pTSuffix

cN cN1 pN

cN Suffix

pNSuffix

cM cM0 pM

cStage 1 pStage 1

Which AJCC chapter do we use?◦Primary Site C10.2

◦Histology 8070/3

◦HPV Status p16 Positive

Chapter 10

What would the stage be if the patientWas p16 negative (see page 130)

pT2

pN1

cM0

Pharynx 2018 10/4/18


Summary Stage/EOD

Scenario 2 49

Data Item Value

Summary Stage 3‐Reg to LN


EOD Regional Nodes 500

EOD Mets 00

500-Pathological evaluation onlyRegional lymph node(s) involved

SSDI’s

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Data Item Value

Extranodal Extension H&N Clin 0

Extranodal Extension H&N Path 0.3

Lymph Nodes Size of Metastasis 021

SEER_SSF1: SEER Site‐Specific Fact 1: Human Papilloma Virus (HPV) Status

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Pharynx 2018 10/4/18


Questions?

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The Role of Radiation Therapy inthe Management of Pharyngeal CancerWILSON APOLLO, MS, CTR, RTT

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Pharynx 2018 10/4/18


Questions?

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Fabulous Prize Winners

5454

Pharynx 2018 10/4/18


Coming UP…Collecting Cancer Data: Breast

• 12/06/2018

Collecting Cancer Data: Testis• 01/10/2019

CE Certificate Quiz/SurveyPhrase

Link

https://www.surveygizmo.com/s3/4656348/Pharynx‐2018

pharynx - naaccr.org · regionalnodes pos 01 regionalnodes ex 25 eod primary tumor 800 eod lymph...

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